Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique.

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Designing an ethnographic interview for evaluation of micronutrient powder trial: Challenges and opportunities for implementation science.

The evidence base for micronutrient powder (MNP) interventions predominantly consists of quantitative studies focused on measuring coverage, utilization, and/or biological outcomes. We need other types of studies to broaden the scope of our knowledge about determinants of MNP programme effectiveness. Addressing this knowledge gap, this paper focuses on the process of designing an ethnographic research protocol to obtain caregivers' perspectives on the factors that influenced their use of intervention delivery services and their adherence to MNP recommendations. The research was undertaken within the context of formative evaluations conducted in Mozambique and Ethiopia. Ethnography provides a means for acquiring and interpreting this knowledge and is an approach particularly well suited for formative evaluation to understand the response of a population to new interventions and programme delivery processes. We describe decisions made and challenges encountered in developing the protocol, and their implications for advancing methodology in implementation research science. In addition to a core team of three investigators, we added an "advisory group" of 10 experts to advise us as we developed the protocol. The advisory group reviewed multiple drafts of the interview protocol and participated in mock interviews. In the protocol development process, we faced the issues and made decisions about concerned gaps in content, cultural adaptations and comprehension, and interview guide structure and format. Differences between the core team and the advisory group in methodological approaches to the structure and content of questions call attention to the importance of establishing greater communication among implementation scientists working in nutrition interventions.

Rethinking integrated nutrition-health strategies to address micronutrient deficiencies in children under five in Mozambique.

In Mozambique, about two thirds of children 6-59 months of age are affected by vitamin A deficiency and anaemia. The objective of this case study is to provide programme considerations for planning, implementing, monitoring, and evaluating vitamin A and iron deficiency interventions within the context of lessons learned to date for vitamin A supplementation, micronutrient powders (MNPs), and food-based strategies. For 15 years, the Mozambique Ministry of Health implemented twice-yearly vitamin A supplementation through both campaigns and routine health services. Yet coverage in 2017 (55%) was not much higher than in 2003 (44%). Reaching every district/reaching every child, a strategy adapted from the field of immunization, was used to achieve equitable coverage of vitamin A and for microplanning of outreach services in health facilities, with support from the Maternal and Child Survival Program. In Mozambique, a free or subsidized distribution model for MNPs has been rolled out, yet integration of MNPs into infant and young child feeding programming (i.e., cooking demonstrations) is needed to reinforce "the who, what, and why" of MNPs through culturally sensitive behaviour change communication. Food-based strategies to promote dietary diversity, such as through complementary feeding recipes, are also critical. To harmonize efforts, the Mozambique government should consider the development of a national strategy for the prevention and control of micronutrient malnutrition, with clear monitoring and evaluation targets. Ongoing monitoring of the prevalence of micronutrient deficiencies and coverage of implemented micronutrient interventions is needed to make evidence-based decisions to drive nutrition-health programming.